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Steve MacArthur

Steve MacArthur is a safety consultant based in Bridgewater, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

I need to know – the re-rise of glutaraldehyde-based disinfectant

One of the developments of the last few years that pleased me most was the move away from glutaraldehyde-based disinfectants to safer alternatives. But now—and I am at a loss to understand what is prompting this—I am seeing a resurgence in the use of the glutaraldehyde-based disinfectants. As we are more or less familiar, glutaraldehyde is a fairly complicated environmental hazard to manage (not the most complicated, but up there on the list), with requirements regarding monitoring of conditions, ventilation, etc. For the big picture, the following link will do nicely: www.osha.gov/Publications/glutaraldehyde.pdf

So what is pushing us back toward a, oh I don’t know, certainly a more hazardous material? You’ll get absolutely no argument from me when it comes to the importance of properly disinfecting reusable medical devices; the rate of hospital-acquired infections is so much greater than we as safety professionals can live with. I had heard of some instances in which devices like endoscopes were stained following disinfection using OPA-like products, but my understanding was that any discoloring on the surface of devices was residue of proteinaceous materials that weren’t completely removed during the pre-disinfection process. (You can’t really call it staining as these devices are generally impermeable, so if it can’t sink in, it can’t stain.) So, I ask you: What up with this? I want to be able to help folks move in the right direction, and I’m not convinced that moving back toward glutaraldehyde is the right direction. If you folks are privy to something that allows this to make sense, please share. It is, after all, the time of the season. Hope to hear from you soon.

A cup of coffee, a sandwich, and…the boss!

If you’ve not yet procured a copy of the November 2011 issue of The Joint Commission Perspectives, I would encourage you to do so. There is a very interesting article that focuses on a strategy for establishing more effective communication between the folks charged with managing the physical environment (that would be you) and hospital leadership.  Now I think this is a pretty cool idea, but I couldn’t say with any degree of certainty how widespread a success it might be as there are a number of variables involved (and that’s not counting personalities). That said, it’s certainly a strategy worth pursuing, if it doesn’t pursue you first.

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A little more conversation – and a little more action too!

By this point, you should be thinking about (or already acted on) setting up conversations with your testing vendors to ensure that your fire protection systems testing, inspection, and maintenance documentation reflects the requirements as outlined in EC.02.03.05, Element of Performance #25. Your vendor (and, as the end game, you) is on the hook to provide the following information:

-          The name of the activity

-          The date of the activity

-          The required frequency of the activity (i.e., quarterly, annually, etc.)

-          The name and contact information, including affiliation of the person who performed the activity

-          The NFPA standard(s) referenced for the activity

-          The results of the activity (usually pass or fail)

I’m sure you’ll remember past discussions regarding testing documentation. If you need a refresher, click here. We know that there continues to be a fair amount of survey vulnerability when it comes to this area—it’s still in the top 10 most frequently cited standards for 2011. Clearly, there are some very specific expectations in play here. The actual content and context of those expectations might still be a wee bit murky, but hey, what are you going to do? Ithink it’s time to make sure that our testing vendors are singing from the same hymnal.

Follow the leader

Another survey condition that has been surfacing of late—which you could say makes it a “sighted citation—” is the bundling of EC-LS-EM findings and generating a further finding under Leadership for not ensuring that the care environment was appropriately managed. Generally, this seems to occur when there are “enough” EC-LS-EM findings to drive a condition-level status as a function of the CMS Conditions of Participation. Unfortunately, at least at the moment, it is not clear how much “enough” is required to drive the finding to this precarious level.

Not having personally participated in the applicable surveys, I can’t tell whether or not there may have been mitigating circumstances that resulted in the survey team feeling that the organization was not appropriately mustering resources to manage risk in the physical environment. That said, I can certainly tell you that one of the things that seems to thread its way through these findings is a gap in correcting deficiencies identified during maintenance and testing, including timely follow-up testing for failed systems, and timely follow-up in general. It is absolutely imperative that we have a process for managing identified deficiencies, including the identification of any interim measures (these ain’t just for life safety folks any longer, boys and girls) that would be implemented to compensate for the deficiencies. It is clear to me that there has been a shift toward the ongoing management of deficiencies through a formal process, at least in terms of survey expectations.

Although it is well understood that healthcare is not swimming in money, our overall charge is to ensure that the care environment is appropriately managed at every moment of every day; people’s lives are potentially at risk here, and we have got to be absolutely certain that we are doing everything in our power to protect them.


I can’t drive – 5?

I recently fielded a question regarding vehicle speed limits on a hospital campus.

I think we can agree that we don’t want folks tearing around our grounds, running into or over people and things, but are there specifics involved? (I think I’m smelling a risk assessment here…)

The situation presented to me revolved around a current practice of posting 5 miles per hour as the campus speed limit, which, as I’m sure you can imagine, can be tough to enforce, regardless of whether you live in NASCAR country. So, the question became: Can the campus speed limit be raised to 10, or even 15, miles per hour?

To my fairly certain knowledge, there is no definitive nationwide regulatory source that would come into play; but, as you can well imagine, there are a number of Authorities Having Jurisdiction who might be willing to offer some assistance in this regard. My immediate thought (and probably the most useful) would be to check with municipal law enforcement to see what they might recommend/require in this regard, and move forward accordingly. I’m thinking that there would be only minor, if any, objection to a raise of the limit to 10 miles per hour, and maybe even 15 miles per hour. But checking with the law enforcement folks is a very fine place to start.

So, how fast can you go?

What we have here is a failure to communicate, or is it a water failure? Sewer failure?

Another survey finding that’s been bubbling up to the top lately relates to your utility system disruption/failure response plans. EC.02.05.01, EP #9 requires hospitals to have written procedures for responding to utility system disruptions. I’ve seen a number of folks tagged for not having the full “suite” of response procedures; if you have a utility system, then you need to have a written procedure for responding.

Now I would think that as a function of your incident command structure, (which is, like, totally compliant with the requirements of the National Incident Management System), you should be able to appropriately manage utility disruptions. However, I guess that sort of begs the question: Do you stand up your IC for utility systems issues or is there a reluctance (or something similar to that) to pull the trigger when push comes to a little bigger push? And, once again, it comes down to how (and perhaps more importantly, how well) you educate/communicate/simplify your frontline folks.

My general experience, fortunately, has been that disruptions to single systems tend to be rather more transient than not–something that can be “endured” until we get things back in order. And I think an important consideration when it comes to endurance is having a simple structure, based on what one might consider “normal” operations. This way, staff don’t have to worry so much about getting from Point A to Point Z because they are sufficiently familiar with B, C, D, and so on. They can respond quickly and appropriately, regardless of what’s going on (or isn’t going on, which I guess is a good indicator of a disruption).

So, do you have written plans for each of your utility systems? When’s the last time you had a chance to practice on some of the more esoteric systems? I’d love to hear what folks are doing, and I suspect that I am by no means the only one.

Mac’s Brief on the September TJC Executive Briefings, Part 2

As promised, I continue going the standards The Joint Commission (TJC) unveiled as the top 10 most frequently cited standards for the first six months of survey year 2011 at the annual Executive Briefings meeting. Five (count ‘em) of those standards were in the environment of care (EC)/life safety (LS) world. Here are the last three:

TJC cited 47% of hospitals for LS.02.01.30 (whew, finally under 50%). This is where things went slightly awry for yours truly as it was apparently indicated that the findings (generally under EP #2, which refers to the fire protection features of hazardous areas) have to do with signage. At EB, an example was given of proper labeling of a vent stack from sterile processing that might have hazardous materials (isn’t that why we have EC.02.02.01?) Also mentioned was the concept of the risk assessment (did you really think that was ever going to go away?) to determine what soiled utility rooms should be locked or otherwise secured. Again, my thought was that this was covered under EC.02.02.01 or maybe EC.02.01.01, but in the Life Safety chapter? I didn’t see that one coming!

When it comes to standard EC.02.03.05 (of which 42% of hospitals were cited), I think the safety community has to come together and convince our maintenance and testing vendors that we are sick and tired of having our heads handed to us because they “buried” some deficiency on page 17 of a report only to have the surveyor find the stinking thing and say, “So, what about this?” We need to have a list of deficiencies identified during any maintenance and testing activity provided to us, before the vendors leave the building. We can no longer afford to wait a month or six weeks to get the report of findings; the clock starts ticking the moment these concerns are identified and we need to be jumping on them quickly and assertively, which may entail including the implementation of some sort of interim measure to ensure that we are not placing folks at risk. I absolutely understand that doing so is, in many ways, nothing but a pain in the tuchus; but until such time, as we are proactively managing this stuff, this is going to continue to be among the most frequently cited standards. I say we end it here—who’s with me? FREEDOM! Sorry, got a bit carried away there. Must be ‘cause I’m wearing my (metaphorical) kilt . . .

Finally, LS.02.01.35 (of which 36% of hospitals cited): This standard relates to all things sprinklers—the 18- inch rule, stuff hanging on sprinkler piping, cabling tied to sprinkler supports, all that stuff. Again, this is very much a numbers game. What’s the likelihood that somewhere, above some ceiling, the cable monkeys have run some conduit or other detritus over a sprinkler line or tied it to a support? Very bloody likely, I’d say, very bloody likely.

Getting back to this infection control thingy (as promised in my last post), it was announced that the life safety surveyors are receiving education relative to basic IC issues, including scope cleaning and the separation of clean and dirty scopes. The announcement brought up a thought—for those of you with not-so-generously-proportioned scope cleaning areas, particularly when the soiled and clean processes are separated only by distance and not by a physical barrier, you might want to consider a risk assessment to determine whether your processes are pristine. I know you are doing the best you can, but sometimes you have to take those types of decisions out, dust ‘em off, and look at them again to make sure they are still viable. It may be your only defense during a survey, and I say you can’t have too many of them, only not enough.

For those of you not so executively inclined: Mac’s Brief on the September TJC Executive Briefings

To the surprise of almost no one (as far as I can tell), when The Joint Commission (TJC) unveiled the top 10 most frequently cited standards for the first six months of survey year 2011 at the annual Executive Briefings meeting, five (count ‘em) of those standards were in the environment of care (EC)/life safety (LS) world. Each standard relates directly to the increasing coverage of the life safety surveyors. It also appears that their scope is going to be expanding into the realm of infection control (IC), but more on that in the next blog post (stay tuned).

While the EC/LS world had to settle for second place on the list with LS.02.01.20 (taking third: LS.02.01.10, fourth: LS.02.01.30, fifth: EC.02.03.05, and eighth: LS.02.01.35), it is clear there is a great deal of work yet to be done by hospitals to gain a little control over this deluge of deficiencies.

A whopping 57% of hospitals surveyed between January and June were cited on LS.02.01.20, which has everything to do with maintaining the integrity of egress. Hospitals were caught for a number of deficiencies: doors locked in a means of egress, projections, corridor clutter, and configuration/designation of suites.

My colleague Brad Keyes and I have spoken (some would say approaching ranting) about the importance of your life safety drawings and how they facilitate the survey process if they are accurately maintained. It appears the quality (or lack thereof) of life safety drawings are more frequently put to the test during survey, with not-so-glowing results. (I’m interpreting a 43% success rate as something less than A-level performance.) I suspect that a majority of the findings might still relate to corridor clutter (after all, how difficult is it to find two instances of unattended, unallowed stuff in the corridor, hmm?) Interestingly enough it was revealed that one cannot manage the corridor clutter LS deficiency through the plan for improvement (PFI) process, which is kind of stinky.

My opinion is that if you do your risk assessment for interim life safety measures (ILSM) to compensate for the LS deficiency represented by corridor clutter and actually resolve it in some way, then that is an appropriate use of the process. But, in this case—and so many others, it makes my head spin—my opinion matters not a whit. So egress woes top the list.

Moving on to LS.02.01.10, which also has a 57% rate of findings in hospitals for the first half of 2011. This one’s fairly straightforward: doors (not latching), doors (undercuts), doors (lacking closers), more doors (can anyone say door stops?), and then sealing around ductwork penetrating fire-rated barriers. Again, how difficult is it to find this stuff (and yes, I know that it is our job to make it difficult, but still…) Once again, accurate life safety drawings are the key; if your drawings say door is a fire door, then that’s how it will be surveyed, even if it’s a smoke door now since you’ve sprinkled your building–the drawings never lie!)

More top-cited standards will be discussed in the next blog post–stay tuned!

This is a public service announcement

This is a public service announcement—with guitars! (Okay, maybe not guitars) or perhaps this will work:

Money well spent…imagine that.

Every once in a while I like to share stuff that folks are developing in other areas of concerns/disciplines, and I think this one is a peach. In fact, I think it’s so useful, I’m just going to thank my good friend and colleague Marge McFarlane for sharing this with me, which helps me to share with you, and then shut the heck up:

The American College of Emergency Physicians is proud to announce the release of its newest training, Hospital Evacuation: Principles and Practices. The training can be found here

We hope that you take the time to view the course and pass the information along. A description of the course can be found below:

“Healthcare facilities must be ready to tackle anything that comes their way. In times of disaster, natural or technological, they must remain open, operational, and continue carrying out their functions. When the situation escalates to a level that endangers the health and/or safety of the facilities patents, staff, and visitors, evacuation of the endangered areas is necessary. Safety and continuity of care among evacuees during a disaster depend on planning, preparedness, and mitigation activities performed before the event occurs. At the completion of the course, hospitals and other healthcare providers with inpatient or resident beds will have basic training and tools to develop an evacuation plan. This one-hour course will take the participant through the stages of preparing for a facility evacuation. It begins by performing an assessment of possible vulnerabilities and the resources available to a facility. Next, the course walks the learner through the development of a functional plan for a healthcare facility, and identification of key personnel positions implemented when a facility evacuates and the roles and responsibilities of each. The course concludes by addressing recovery issues, both plan development and operational.”

Good stuff, and I encourage each one of you with anything more than a passing interest in such things to check it out.

And now for something completely…the same

Time for a quick roundup of some recent survey trends:


  • We’ve talked about the overarching issues with weekly testing of plumbed eyewash stations any number of times over the years and I am always happy to respond to direct questions. The key element here is that if your organization is not conducting an at least weekly testing regimen for your plumbed eyewash stations and has not documented a risk assessment indicating that a lesser frequency is appropriate, it will likely be cited. My consultative advice: If you’re not testing at least weekly, please do so, or do the risk assessment homework.
  • With the extra life safety surveyor time during survey, the likelihood of encounters with frontline staff is on the rise. And apparently, it is not enough for folks to know what they are doing, but there is also an expectation that they will understand why they do what they do, primarily in the context of supporting patient care (which we all do—everything that happens in a hospital can trace back to the patient). I guess it won’t be enough for folks to be able to respond appropriately when asked how they would respond to a fire. They also need to understand how their response fits into the grand scheme of things. I really believe that folks understand why their jobs are important; we just need to prepare them for the question. Probably more on this as it develops.
  • 96 bottles of beer on the wall, 96 bottles of beer—but will that be enough beer to last 96 hours (I guess it depends on how thirsty you are)? So the question becomes this: If a surveyor asks to see your 96-hour capability assessment, what would you do, and perhaps most importantly, can you account for it in your Emergency Operations Plan? My general thought in this regard is that the 96-hour benchmark would be something that one would re-visit periodically, just as you would your hazard vulnerability assessment, in response to changing conditions, both internal and external.
  • As a final thought for this installment, please make sure that you (that would be the royal “you) are conducting annual fire drills in all those lovely little off-site locations listed as business occupancies on your Statement of Conditions. And make very sure that staff is aware that you are conducting those fire drills. There’s been a wee bit of an upsurge in fire drill findings based on the on-site staff not being able to “remember” any fire drills, in some instances, for several years. The requirement is annual and I don’t think any of us wishes to get tagged for something as incidental as this one.